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Diabetes insipidus: diagnosis and treatment

Diabetes insipidus is a rare but treatable condition that usually occurs with polydipsia and polyuria. But distinguishing these symptoms from the symptoms of primary polydipsia, diabetes mellitus and other causes of frequency without polyuria can be very difficult. Diabetes insipidus is rare, with a prevalence of 1 in 25,000 people.

Central diabetes insipidus is usually caused by pathologies of the pituitary, either as a result of inflammatory or infiltrative processes or, after surgery of a pituitary tumor, but may also be due to a congenital defect in the production of arginine vasopressin (antidiuretic hormone). ).

Nephrogenic diabetes insipidus is usually caused by electrolyte disturbances, nephropathy or pharmacological nephrotoxicity (commonly lithium).

Arginine vasopressin causes the reabsorption of water in the collecting tubes of the kidney. The deficiency of the hormone or resistance to it, as in diabetes insipidus, lead to excess water loss by the kidney (polyuria).

Typically, the compensatory impulse is thirst, which will provide adequate rehydration, but in severe cases, when there is no access to water, the person with diabetes insipidus can dehydrate rapidly, which can lead to hyperosmolality, hypernatremia and, potentially, death.

 

 

Presentation of symptoms

Extreme thirst and the emission of large amounts of clear urine are typical symptoms of diabetes insipidus, but it can be difficult to make a differential diagnosis with these symptoms, although indicators can be found in the background and studies, which can help.

In central diabetes insipidus, the history of polyuria and polydipsia tends to be sudden, appearing at weeks or months of onset. In nephrogenic diabetes insipidus, onset is more insidious and patients usually have had symptoms for months or years before diagnosis.

Symptoms that suggest pituitary disease are fatigue, dizziness, irregular menstrual cycles and galactorrhea in women and women, loss of libido and reduction of secondary sexual characteristics in men.

 Investigation of the disease

The presence of diabetes mellitus should be ruled out, confirmed by the formal measurement of fasting or random blood glucose. Serum electrolytes, Diuresis and paired urine and plasma osmolality should also be evaluated.

Patients with suspected diabetes insipidus should be referred to the specialist for further studies and treatment. The urgency of the referral depends on the severity of the symptoms.

If there is extreme thirst and polyuria and the serum osmolality is> 295 mOsmol / kg, the shunt should be done in a few days or a few weeks at most.

Patients with known diabetes insipidus who have hypernatremia should be considered in a state of emergency, which should be resolved on the same day.

 

Treatment

The therapeutic pillars of central diabetes insipidus are the adequate replacement of fluids, the treatment of the underlying pathology and the administration of desmopressin. This analog of antidiuretic hormone can be administered orally or by intranasal spray.

In general, central diabetes insipidus responds immediately to desmopressin, and patients notice a significant reduction in polyuria and thirst. The symptoms of inadequate intake of desmopressin are thirst and polyuria, while the symptoms of excessive replacement are headache and mild confusion (due to hyponatremia), and decreased diuresis.

Nephrogenic insipid diabetes is treated with fluid intake and specific etiological treatment, under the care of a nephrologist. Other treatments include low sodium and hypoproteic diets, diuretics and nonsteroidal anti-inflammatory drugs.

He has recently developed recommendations for the hospital treatment of patients with diabetes insipidus who suffer from an acute illness. These guidelines recommend that all hospitalized patients with central diabetes insipidus be identified on admission and the corresponding endocrinology or clinical team notified.

Any patient with central diabetes insipidus who enters a hospital needs careful monitoring of fluid replacement, as well as the appropriate administration of desmopressin.

It is recommended that hospitals develop an alert system to identify all patients requiring treatment with desmopressin, in order to ensure that medication is not omitted.

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This article was published on Thursday 09 May, 2019.

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